do we have a definition of an unnecessary cesarean section?

Do we have a definition Do we have a definition of an unnecessary of an unnecessary cesarean section?cesarean section?

Asociación Argentina de Ginecología y Obstetricia Asociación Argentina de Ginecología y Obstetricia PsicosomáticaPsicosomática

Servicio de Obstetricia. Hospital Italiano de Buenos Aires. Servicio de Obstetricia. Hospital Italiano de Buenos Aires. ArgentinaArgentina

-Dr. Mario Sebastiani--Dr. Mario Sebastiani-

Unnecesary C- section ?

Published rates

W.H.O.:W.H.O.: 11

• 15 %15 %• Maximum desirable rate of cesarean Maximum desirable rate of cesarean

sectionsection• No benefit for mother and the fetus for No benefit for mother and the fetus for

medical reasonsmedical reasons

11 World Health Organisation. Appropriate technology for birth. World Health Organisation. Appropriate technology for birth. Lancet Lancet 1985;436 7.1985;436 7.


Sweden: 1

59 hospitals59 hospitals 1988 - 19921988 - 1992

• Perinatal mortality Perinatal mortality

• Rate of asphixiaRate of asphixia

1 Eckerlund I, et al.,Eckerlund I, et al., Int J Technol Asses Health CareInt J Technol Asses Health Care 1999;15:123 - 35 1999;15:123 - 35

Minimum cesarean section rate is optimal

No benefitNo benefit

Outcome based study


England 11 17 maternity units (one health region)17 maternity units (one health region) 19881988 36.727 singleton pregnancies36.727 singleton pregnancies

• CS rates should be 10 - 12 % • More intervensionist approach in low birth weight infants1 1 Joffe M, et al., Joffe M, et al., J Epidemiol Community HealthJ Epidemiol Community Health 1994;48:406 - 11 1994;48:406 - 11

Outcome based study


Healthy People 2000 11

Department of Health and Human ServicesDepartment of Health and Human Services 15 % by the year 200015 % by the year 2000

“....the advantages of a safe vaginal delivery over

a cesarean delivery are clear: a vaginal delivery is

associated with lower maternal and neonatal

morbilidity and it costs less...”

11 Healthy People 2000; Healthy People 2000; DHHS DHHS publication Nº. (PHS) 91-50212.publication Nº. (PHS) 91-50212.

Latin America


Grafic I: Incidence of ceasarean secton in Latin American

W.H.O.W.H.O.

Belizán JM, et al, Belizán JM, et al, BMJBMJ 1999;319:1397 -402 1999;319:1397 -402


Grafic I: Incidence of ceasarean secton in Latin American


W.H.O.W.H.O.


““Rates and implications of caesarean sections Rates and implications of caesarean sections in Latin America: ecological study”in Latin America: ecological study”

12 of 19 Latin American countries12 of 19 Latin American countries

81% of the deliveries 81% of the deliveries

C-S rates above 15% (16,8% - 40%)C-S rates above 15% (16,8% - 40%)

Better socioeconomic conditions = higher C-S ratesBetter socioeconomic conditions = higher C-S rates

Over 850.000 unnecesary c-sections are performed each Over 850.000 unnecesary c-sections are performed each

year in LAyear in LA



Why has the rate of cesarean delivery climbed so dramatically in the past 25 years?

1.1. Lower toleranceLower tolerance for taking risks for taking risks

2.2. Fear of malpractice litigationFear of malpractice litigation

3.3. IncreasedIncreased use of epidural anesthesia ?use of epidural anesthesia ?

4.4. Increased use of electronic fetalIncreased use of electronic fetal monitoringmonitoring

5.5. The convenience of physiciansThe convenience of physicians

Sachs BP et al., Sachs BP et al., NEJMNEJM 1999;340:54 – 57 1999;340:54 – 57


Difficulties for the analysis Which is the optimun cesarean rate?Which is the optimun cesarean rate? Many stategies to reduce the ratesMany stategies to reduce the rates



Vaginal Birth=

Quality

Caserean Section=

Clasical indicaton or failure

Medical and non medical reason



Is there a different view ?

Vaginal Birth=

Quality

Caserean Section=

Clasical indicaton or failure


Who are involved ?

FETUS MOTHER

Childbirth


Who are involved ?

Obstetricians

FETUS MOTHER

Health system

Obstetrical Uni-HospitalMidwives

Society

Childbirth


Factors involved in decision

1.1. Fetal mortality and morbidityFetal mortality and morbidity2.2. Newborn healthNewborn health3.3. VBACVBAC4.4. Cost Cost 5.5. Pelvic floor damage Pelvic floor damage 6.6. Maternal mortalityMaternal mortality7.7. Cultural factorsCultural factors8.8. Autonomy - C-section on demand?Autonomy - C-section on demand?


Cotzias C, Paterson-Brown S, Fisk N. BMJ, 319,31 july 1999Cotzias C, Paterson-Brown S, Fisk N. BMJ, 319,31 july 1999

Weeks Nº of pregnancies Prospective Risk of fetal death

35 164 860 1:366 36 162 603 1:407 37 158 171 1:474 38 149 181 1:529 39 127 160 1:617 40 93 828 1:680 41 39 316 1:606 42 10 328 1:565 43 1 883 1:465

““Unexplained fetal deaths”Unexplained fetal deaths”


Could C-S reduce fetal death rate?

5 times more frequent than SIDS5 times more frequent than SIDS Termination of pregnancy when fetal risks Termination of pregnancy when fetal risks in útero in útero

are larger than the risks of the newborn: are larger than the risks of the newborn: 1/5001/500 Most of fetal deaths occur in non-malformed Most of fetal deaths occur in non-malformed

fetusesfetuses

Cotzias C, et al.,Cotzias C, et al., BMJ BMJ, 319,31 july 1999, 319,31 july 1999


Could C-S reduce fetal death rate?

5 times more frequent than SIDS5 times more frequent than SIDS Termination of pregnancy when fetal risks Termination of pregnancy when fetal risks in útero in útero

are larger than the risks of the newborn: are larger than the risks of the newborn: 1/5001/500 Most of fetal deaths occur in non-malformed Most of fetal deaths occur in non-malformed

fetusesfetuses Women’s preference: C-section of the risk is Women’s preference: C-section of the risk is

> 1:4000 > 1:4000 11Cotzias C, et al.,Cotzias C, et al., BMJ BMJ, 319,31 july 1999, 319,31 july 1999

11 Thornton E, et al., Thornton E, et al., J Obstet GynecolJ Obstet Gynecol 1989;9:283-8 1989;9:283-8


“Effect of Mode of Delivery in Nulliparous Women on Neonatal Intracranial Injury”

1: 664 forceps 1: 664 forceps 1: 860 vacuum extraction1: 860 vacuum extraction 1: 9071: 907 c-section during labor c-section during labor 1: 1900 delivered spontaneously 1: 1900 delivered spontaneously 1: 27501: 2750 c-section with no labor c-section with no labor

Towner D et al., Towner D et al., NEJMNEJM 1999;341:23 1999;341:23

Conclusion:Conclusion: The common risk factor for The common risk factor forhemorrhage is abnormal laborhemorrhage is abnormal labor


All c-sections

Primary c-section

VBAC

Frequency of cesarean section, primary cesarean and vaginal birth post-c-section between 1989 - 2001

Martin JA, Martin JA, et al., et al., National Center for Health StatisticsNational Center for Health Statistics. 2002 . 2002


Recomendations

The most conservative recomendations.The most conservative recomendations.

• ACOG Technical Bulletin. Vaginal delivery after a previous ACOG Technical Bulletin. Vaginal delivery after a previous

cesarean birth. cesarean birth.

• Int J Gynecol ObstetInt J Gynecol Obstet 48:127 – 129; 48:127 – 129; 1995.1995.

• ACOG Vaginal birth after a previous cesarean. ACOG Vaginal birth after a previous cesarean.

• ACOG Practice BulletinACOG Practice Bulletin N° 5:1 – 8; N° 5:1 – 8; 1999.1999.


VBAC Over 1000 reports: not one RCTOver 1000 reports: not one RCT


VBAC Over 1000 reports: not one RCTOver 1000 reports: not one RCT

Economic forces rather than patient well-Economic forces rather than patient well-

being, are driving the goal of fewer being, are driving the goal of fewer

cesarean sections ? cesarean sections ? 11

1 1 Clark S., et al., Clark S., et al., Am J Obstet Gynecol Am J Obstet Gynecol 2000;182:599-6022000;182:599-602


Costs of deliveries CesareanCesarean delivery:delivery:

• Costs more than a vaginal delivery Costs more than a vaginal delivery • Longer hospital stay Longer hospital stay • Use of an operating room.Use of an operating room.

LaborLabor unit:unit: a prolonged and difficult labor, even a prolonged and difficult labor, even when it results in a vaginalwhen it results in a vaginal delivery, is more delivery, is more costly to an institution than a cesarean deliverycostly to an institution than a cesarean delivery..


Beth Israel Deaconess Medical Center, Boston, USA

ElectiveElective repeated cesarean delivery $ 7.700 repeated cesarean delivery $ 7.700

Normal vaginal delivery $ 6.800Normal vaginal delivery $ 6.800

Intrapartum Cesarean: $ 10.000 Intrapartum Cesarean: $ 10.000

Costs of deliveries


Beth Israel Deaconess Medical Center, Boston, USA

ElectiveElective repeated cesarean delivery $ 7.700 repeated cesarean delivery $ 7.700

Normal vaginal delivery $ 6.800Normal vaginal delivery $ 6.800

Intrapartum Cesarean: $ 10.000 Intrapartum Cesarean: $ 10.000

ComplicationComplication

• Mother: + $ 4.000 Mother: + $ 4.000

• Child: + $ 2.000Child: + $ 2.000

Costs of deliveries


Difficulties in the estimation of costs

Poor quality:Poor quality: what resources were included what resources were included in their cost estimatein their cost estimate

Lack of progress of labor > more hospital Lack of progress of labor > more hospital

lenght > medical costs > nursing costslenght > medical costs > nursing costs ChargesCharges are not the same as are not the same as costscosts Long term sequelae:Long term sequelae: Pelvic floor - Fetal Pelvic floor - Fetal

mortality - Newborn trauma mortality - Newborn trauma Malkin J, et al., Malkin J, et al., BirthBirth 2001;28:208-9 2001;28:208-9



1.1. Fetal mortality and morbidityFetal mortality and morbidity2.2. Newborn healthNewborn health3.3. VBACVBAC4.4. CostCost 5.5. Pelvic floor damage Pelvic floor damage 6.6. Maternal mortalityMaternal mortality7.7. Cultural factorsCultural factors8.8. Autonomy - C-section on demand?Autonomy - C-section on demand?


Pelvic floor

Urinary incontinenceUrinary incontinence

Fecal incontinenceFecal incontinence

Sexual dysfunctionSexual dysfunction

Organ prolapseOrgan prolapse


Pudendal nerve damagePudendal nerve damage Soft tissue traumaSoft tissue trauma The levator musculature traumaThe levator musculature trauma Anal sphincter traumaAnal sphincter trauma

Pelvic floor


Pudendal nerve damagePudendal nerve damage Soft tissue traumaSoft tissue trauma The levator musculature traumaThe levator musculature trauma Anal sphincter traumaAnal sphincter trauma

11 Davila GW, et al., Davila GW, et al., Int Urogyneocl JInt Urogyneocl J 2001;12:289-291 2001;12:289-291

““...neurophysiologic studies have demonstrated the ...neurophysiologic studies have demonstrated the etiologic role of parturition-related nerve damage in etiologic role of parturition-related nerve damage in development of pelvic floor disfunction...”development of pelvic floor disfunction...”11

Pelvic floor


Reduction of pelvic floor damage

Minimizing forceps deliveriesMinimizing forceps deliveries

Minimizing episiotomiesMinimizing episiotomies

Allowing passive descent in the second stageAllowing passive descent in the second stage

Selectively recomending elective cesarean Selectively recomending elective cesarean

deliverydelivery

Davila GW, et al., Davila GW, et al., Int Urogyneocl JInt Urogyneocl J 2001;12:289-291 2001;12:289-291


Avoid laborAvoid labor Avoid passage of the fetus through the pelvisAvoid passage of the fetus through the pelvis Shorten second stageShorten second stage Avoid routine episiotomyAvoid routine episiotomy ForgetForget the forceps specially in macrosomia the forceps specially in macrosomia Repair perineal damageRepair perineal damage

Devine II, Devine II, Contemporary Ob/GynContemporary Ob/Gyn 1999:119 1999:119

Prevention of pelvic floor damage


Risk of maternal death““...the presumed increased risk of maternal death with ...the presumed increased risk of maternal death with

elective cesarean delivery traditionally has been the elective cesarean delivery traditionally has been the

most compelling reason to reject a policy of universal most compelling reason to reject a policy of universal

cesarean delivery or "cesarean on demand." cesarean delivery or "cesarean on demand."

However, good evidence is accumulating that this is However, good evidence is accumulating that this is

no longer true; the maternal morbidity and mortality no longer true; the maternal morbidity and mortality

from elective cesarean delivery at term before the from elective cesarean delivery at term before the

onset of labor appear to be similar to those onset of labor appear to be similar to those

associated with vaginal birth....”associated with vaginal birth....”Hannah ME, Hannah ME, LancetLancet 2000;356:1375-83 2000;356:1375-83.


Cultural phenomena - Brazil All birth are attended by obstetriciansAll birth are attended by obstetricians TrainingTraining Doctors work in the public and private health Doctors work in the public and private health

systemsystem Status of c-section: modern and technicalStatus of c-section: modern and technical Women’s body are perceived as sexual than Women’s body are perceived as sexual than

maternalmaternal Genitals are perceived for sexual activity than Genitals are perceived for sexual activity than

for childbearingfor childbearingNuttall C., et al., Nuttall C., et al., BMJBMJ 2000;320:1072 2000;320:1072


Cesarean section on demand

31% of female obstetricians would prefer a 31% of female obstetricians would prefer a

cesarean delivery for themselves cesarean delivery for themselves 11

11 Al-Muffti et al. Al-Muffti et al. Eur J Obstet Gynecol Reprod Biol Eur J Obstet Gynecol Reprod Biol 1997:73:1-41997:73:1-4


Cesarean section on demand

31% of female obstetricians would prefer a 31% of female obstetricians would prefer a

cesarean delivery for themselves cesarean delivery for themselves 11

Italian law mandates that women be given the Italian law mandates that women be given the

option of an elective cesarean, and about 4% option of an elective cesarean, and about 4%

of pregnant women choose it. of pregnant women choose it. 22

11 Al-Muffti et al. Al-Muffti et al. Eur J Obstet Gynecol Reprod Biol Eur J Obstet Gynecol Reprod Biol 1997:73:1-41997:73:1-4

22 Tranquilli AL, et al., Tranquilli AL, et al., Am J Obstet GynecolAm J Obstet Gynecol 1997;177:245-246 1997;177:245-246


Autonomy

Is the governing principle in medicineIs the governing principle in medicine

We respect with better eyes a woman’s right We respect with better eyes a woman’s right

to refuse a cesarean deliveryto refuse a cesarean delivery

Nobody is interested in respecting woman’s Nobody is interested in respecting woman’s

desire to refuse vaginal deliverydesire to refuse vaginal delivery

Wagner M et al., Lancet 2000;356:1677-80Wagner M et al., Lancet 2000;356:1677-80


Autonomy and informed consent

Full and umbiased information Full and umbiased information

(better=efficacy and worse=risks)(better=efficacy and worse=risks)

Do we have the time to inform ?Do we have the time to inform ?

Male dominated obstetric modelMale dominated obstetric model

Does a woman have an inalienable “right” to Does a woman have an inalienable “right” to

choose a C-S ? choose a C-S ? Wagner M et al., Lancet 2000;356:1677-80Wagner M et al., Lancet 2000;356:1677-80


Autonomy and informed consent

““...performing cesarean section for non medical ...performing cesarean section for non medical

reasons is ethically not justified....”reasons is ethically not justified....”

Committee for the Ethical Aspects of Human ReproductionCommittee for the Ethical Aspects of Human Reproduction and Women’s Health of and Women’s Health of FIGO (1999)FIGO (1999)


Ambiguity of terms

Natural as desirableNatural as desirable

Natural as hazardousNatural as hazardous

C-section as safeC-section as safe

C-section as beneficial for doctorsC-section as beneficial for doctors


Natural (phylosophy of terms)

To approve or excuse a behavior. UnnaturalTo approve or excuse a behavior. Unnatural Ecologist’s feeling against the danger of the Ecologist’s feeling against the danger of the

naturenature Natural is everything that belong to the Natural is everything that belong to the

Universe (animate or liveless, rational o Universe (animate or liveless, rational o irrational) irrational) ((Stuart Mill)Stuart Mill)

Dynamic and historical conceptDynamic and historical concept


Artificial (phylosophy of terms)

What is produced by the arts and human technicsWhat is produced by the arts and human technics Learned, modified. Natural is biologic.Learned, modified. Natural is biologic. Natural in humans is not to be as much. Natural in humans is not to be as much. (Savater)(Savater)

Artificial is better than natural. Which is the Artificial is better than natural. Which is the meaning of arts? meaning of arts? (Savater)(Savater)

Human Human Life is precisely to be different from natureLife is precisely to be different from nature


What do we need

1.1. RCTRCT: intention of labor : intention of labor vsvs elective c-section elective c-section

2.2. To accept that is a To accept that is a cultural phenomenacultural phenomena

3.3. Need of a medical and non medical Need of a medical and non medical

approachapproach

4.4. Informed ConsentInformed Consent


To thinkA change in the birth of human specie has been A change in the birth of human specie has been

produced in the last years The same produced in the last years The same happened in terms of fertilization. It is not happened in terms of fertilization. It is not mediated by a natural evolution, Darwinian, mediated by a natural evolution, Darwinian, but by an artificial evolution of human being.but by an artificial evolution of human being.

This controversy must not be solved replacing This controversy must not be solved replacing vaginal birth with c-section, but stimulating vaginal birth with c-section, but stimulating women’s informed consent regarding the women’s informed consent regarding the aspects of birth.aspects of birth.


To think The nature of birth is related with the female’s The nature of birth is related with the female’s

function as a reproductive agent. Is the same function as a reproductive agent. Is the same

for the women’s condition?for the women’s condition? 9 month not natural and then a natural birth9 month not natural and then a natural birth Have we done a damage?Have we done a damage? You can do....but , should you do it?You can do....but , should you do it? Women’s selection for vaginal birthWomen’s selection for vaginal birth


Conclusion

““...perhaps the time has come when the risks, ...perhaps the time has come when the risks,

benefits and costs are so balanced between benefits and costs are so balanced between

cesarean section and vaginal delivery that the cesarean section and vaginal delivery that the

deciding factor should simply be the mother’s deciding factor should simply be the mother’s

preference for how her baby is to be preference for how her baby is to be

delivered...”delivered...”William Benson HarerWilliam Benson Harer


The cesarean section should not be used as an The cesarean section should not be used as an

indicator of quality of obstetrical careindicator of quality of obstetrical care

We do not have a good definition of unnecesary We do not have a good definition of unnecesary

c-sectionc-section

Conclusion

Thank you.Thank you.

Asociación Argentina de Ginecología y Obstetricia Asociación Argentina de Ginecología y Obstetricia PsicosomáticaPsicosomática

Servicio de Obstetricia. Hospital Italiano de Buenos Aires. Servicio de Obstetricia. Hospital Italiano de Buenos Aires. ArgentinaArgentina

-Dr. Mario Sebastiani--Dr. Mario Sebastiani-

do we have a definition of an unnecessary cesarean section?

Documents

studyunnecesary c section

ratesunnecesary c section

unnecesary csections

cotzias c

unnecessary cesarean

minimum cesarean section

deliveries cs rates

higher cs ratesover